Battle of the bulge: Does treating obesity as a disease help?

Harping on people ad nauseam to lose weight is rather "sadistic", there's little evidence the treatment of obesity works and even the benefits of weight loss are debatable.

In arguments like these, being played out in the official journal of the College of Family Physicians of Canada, doctors are debating whether it's futile to try to treat obesity.

"The few patients who manage to lose weight and keep it off achieve something truly remarkable. From a public health standpoint, however, the treatment of obesity is a failure," writes Dr. Jana Havrankova, of Clinique familiale Saint-Lambert in Quebec, in the current edition of Canadian Family Physician.

One weight-loss drug after another has been pulled off the market over serious harms and the long-term effects of existing treatments remain controversial, adds associate scientific editor Dr. Roger Ladouceur in an accompanying editorial.

"Why, then, do we tell our patients to lose weight?" he asks.

"Why do we repeat, 'You should lose weight'? What's with that? Somewhat sadistic, don't you think? Do we do this as a way of shifting the guilt and transferring the responsibility of the therapeutic failure?"

The statements, observers say, reflect a remarkable and possibly significant shift away from the prevailing medical dogma that everyone who is obese needs to lose weight.

No one is claiming that obesity is harmless. Havrankova says the evidence of obesity's health-damaging effects is "irrefutable" and the costs to society and individuals "astronomical."

Yet, "there is very little evidence that the treatment of obesity works," Havrankova said. Of the studies done, most are of mediocre quality and, for the small percentage of patients who succeed, the weight loss is modest, and gradually regained over time.

"For every individual who wants to lose weight, I maintain hope," Havrankova stressed.

But prevention, starting in early childhood, "offers the best hope in the fight against obesity," she said.

In his editorial — "Should we stop telling obese patients to lose weight?" — Ladouceur says the genetic, environmental and societal factors linked to obesity are "deeply rooted" within us. "It is very difficult for us to change."

Given that, he asks, "Shouldn't we put a stop to this preoccupation with our patient's weight" and simply encourage healthy lifestyle habits, including a balanced diet and exercise, "even if it is simply walking?"

The debate reflects a "clear departure" from the message patients typically hear, said Dr. Arya Sharma, professor of medicine and chair in obesity research and management at the University of Alberta, and scientific director of the Canadian Obesity Network.

"It's moving to a point where we are becoming much more realistic — simply telling people to lose weight and leaving them pretty much up to their own resources is not the way to go," he said. "We have to be much more reflective: For whom is there really likely to be a benefit?"

Sharma's group says that any discussion about weight must begin with the doctor first asking the patient's permission. It's one of the cornerstones of a new roadmap for doctors the network is launching Tuesday. Called the "5 A's of obesity management" — ask, assess, advise, agree, assist — the checklist is designed to help doctors and other health care workers broach the subject in a sensitive and non-judgmental manner.

Today in Canada, overweight and obesity are the new norm. There are more overweight Canadians than there are those of "normal" weight.

Currently, 59 per cent of adult Canadians are either overweight or obese. Unless trends change, by 2026 the proportion will reach 70 per cent, according to estimates presented in March at a federal-provincial summit on the issue.

At any given time, 36 per cent of the population is trying to lose weight.

But, according to a review article published in the same edition of the journal, people in the "high-normal" or overweight range have the lowest mortality, or risk of dying.

"In terms of your chances of dying related to your weight, your best bet is to be slightly overweight," said the study's author, Dr. John Bosomworth, an honorary lecturer in the department of family medicine at the University of B.C. in Vancouver and a retired family physician.

People whose weight remains stable at any level throughout adult life also tend to have a lower risk of dying, he said.

He cautions that most of the studies are observational — meaning researchers simply followed large populations over time, looking at who gained weight, lost weight or stayed the same. They don't prove cause and effect.

But evidence is mounting that a significant proportion of overweight people are metabolically healthy and that the risks associated with obesity require a more sophisticated approach.

"We don't seem to have to beat ourselves up about being overweight in terms of our health unless we have a health-related problem, such as diabetes or heart disease," Bosomworth said. Among the obese — meaning those with a body mass index of 30 or more — about 80 per cent have a weight-related health problem. In those cases, "you have an argument that perhaps weight loss, if you could ever achieve it, might be a good thing," Bosomworth said.

"But there's also the argument — why are you aiming for weight loss, since nobody's succeeding anyway? What's important is physical and metabolic fitness — and that can happen without weight loss.

"Maybe we should be giving them a pedometer and say, 'Why don't you increase your number of steps by 2,000 over the next two weeks every day, bring it back and show me what you've done,' and not worry about the weight."

In a counter-argument, Dr. Dominique Garrel, of Universite de Montreal in Quebec, argues that obesity "must be treated" given the consequences of excess weight. People can improve their health considerably, he said, by losing even five to 10 per cent of their weight.

Garrel said surgery "is very popular and increasingly simple and safe" and suggested patients be referred to specialized teams of nutritionists, psychologists and kinesiologists.

He acknowledged that the $2,000 to $3,000 cost of such care might represent an "insurmountable barrier" for some patients.

"If this is the case the patient can be referred to an organization in the community such as Weight Watchers or Choisir de maigrir."

In her rebuttal, Havrankova asks "where are these teams" and, "most important, what results do they achieve?"

"If there were 'simple' and effective ways to treat obese patients," she said, "we would know it."

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